<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('User_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-user_id" data-source="user.user/index" data-field="username" class="form-control selectpage" name="row[user_id]" type="text" value="{$row.user_id}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Patient_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-patient_id" data-source="patient/index" class="form-control selectpage" name="row[patient_id]" type="text" value="{$row.patient_id}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Service_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-service_id" data-source="service/index" class="form-control selectpage" name="row[service_id]" type="text" value="{$row.service_id}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Service_basic_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-service_basic_id" data-source="service/basic/index" class="form-control selectpage" name="row[service_basic_id]" type="text" value="{$row.service_basic_id}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Hospital_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-hospital_id" data-source="hospital/index" class="form-control selectpage" name="row[hospital_id]" type="text" value="{$row.hospital_id}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Department_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-department_id" data-source="department/index" class="form-control selectpage" name="row[department_id]" type="text" value="{$row.department_id}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Document_type')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-document_type" class="form-control" name="row[document_type]" type="number" value="{$row.document_type}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('begin_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-begin_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[begin_time]" type="text" value="{:$row.begin_time?datetime($row.begin_time):''}" disabled>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Note')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-note" class="form-control" name="row[note]" type="text" value="{$row.note}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Start_address')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-start_address" class="form-control" name="row[start_address]" type="text" value="{$row.start_address}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('End_address')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-end_address" class="form-control" name="row[end_address]" type="text" value="{$row.end_address}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('medicine_type')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-medicine_type" class="form-control selectpicker" name="row[medicine_type]">
                {foreach name="medicineTypeList" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.medicine_type"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Prescription_img')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-prescription_img" class="form-control" name="row[prescription_img]" type="text" value="{$row.prescription_img}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Images')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-images" class="form-control " rows="5" name="row[images]" cols="50">{$row.images}</textarea>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Express')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-express" class="form-control" name="row[express]" type="text" value="{$row.express}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Express_no')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-express_no" class="form-control" name="row[express_no]" type="text" value="{$row.express_no}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Express_img')}:</label>
        <div class="col-xs-12 col-sm-8">
            <textarea id="c-express_img" class="form-control " rows="5" name="row[express_img]" cols="50">{$row.express_img}</textarea>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Express_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-express_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[express_time]" type="text" value="{:$row.express_time?datetime($row.express_time):''}" disabled>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Create_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-create_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[create_time]" type="text" value="{:$row.create_time?datetime($row.create_time):''}" disabled>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Accept_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-accept_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[accept_time]" type="text" value="{:$row.accept_time?datetime($row.accept_time):''}" disabled>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Start_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-start_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[start_time]" type="text" value="{:$row.start_time?datetime($row.start_time):''}" disabled>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('End_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-end_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[end_time]" type="text" value="{:$row.end_time?datetime($row.end_time):''}" disabled>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Add_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-add_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[add_time]" type="text" value="{:$row.add_time?datetime($row.add_time):''}" disabled>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Bed_no')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-bed_no" class="form-control" name="row[bed_no]" type="text" value="{$row.bed_no}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Self_care_ability')}:</label>
        <div class="col-xs-12 col-sm-8">
                        
            <select  id="c-self_care_ability" class="form-control selectpicker" name="row[self_care_ability]">
                {foreach name="selfCareAbilityList" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.self_care_ability"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Finish_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-finish_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[finish_time]" type="text" value="{:$row.finish_time?datetime($row.finish_time):''}" disabled>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Complete_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-complete_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[complete_time]" type="text" value="{:$row.complete_time?datetime($row.complete_time):''}" disabled>
        </div>
    </div>
    <!--<div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Status')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-status" class="form-control" name="row[status]" type="number" value="{$row.status}">
        </div>
    </div>-->
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Status')}:</label>
        <div class="col-xs-12 col-sm-8">
            <div class="radio">
                {foreach name="statusList" item="vo"}
                    <label for="row[status]-{$key}"><input id="row[status]-{$key}" name="row[status]" type="radio" value="{$key}" {in name="key" value="$row.status"}checked{/in} /> {$vo}</label>
                {/foreach}
            </div>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Self_care_ability')}:</label>
        <div class="col-xs-12 col-sm-8">

            <select  id="c-self_care_ability" class="form-control selectpicker" name="row[self_care_ability]">
                {foreach name="selfCareAbilityList" item="vo"}
                    <option value="{$key}" {in name="key" value="$row.self_care_ability"}selected{/in}>{$vo}</option>
                {/foreach}
            </select>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Patient_commented')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-patient_commented" class="form-control" name="row[patient_commented]" type="number" value="{$row.patient_commented}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Worker_commented')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-worker_commented" class="form-control" name="row[worker_commented]" type="number" value="{$row.worker_commented}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Coupon_id')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-coupon_id" data-source="coupon/index" class="form-control selectpage" name="row[coupon_id]" type="text" value="{$row.coupon_id}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Coupon_money')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-coupon_money" class="form-control" step="0.01" name="row[coupon_money]" type="number" value="{$row.coupon_money}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Total_price')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-total_price" class="form-control" step="0.01" name="row[total_price]" type="number" value="{$row.total_price}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Pay_price')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-pay_price" class="form-control" step="0.01" name="row[pay_price]" type="number" value="{$row.pay_price}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Pay_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-pay_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[pay_time]" type="text" value="{:$row.pay_time?datetime($row.pay_time):''}" disabled>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Platform_money')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-platform_money" class="form-control" step="0.01" name="row[platform_money]" type="number" value="{$row.platform_money}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Worker_money')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-worker_money" class="form-control" step="0.01" name="row[worker_money]" type="number" value="{$row.worker_money}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('medicine_price')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-medicine_price" class="form-control" step="0.01" name="row[medicine_price]" type="number" value="{$row.medicine_price}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Refund_status')}:</label>
        <div class="col-xs-12 col-sm-8">
            
            <div class="radio">
            {foreach name="refundStatusList" item="vo"}
            <label for="row[refund_status]-{$key}"><input id="row[refund_status]-{$key}" name="row[refund_status]" type="radio" value="{$key}" {in name="key" value="$row.refund_status"}checked{/in} /> {$vo}</label> 
            {/foreach}
            </div>

        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Refund_money')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-refund_money" class="form-control" step="0.01" name="row[refund_money]" type="number" value="{$row.refund_money}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Refund_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-refund_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[refund_time]" type="text" value="{:$row.refund_time?datetime($row.refund_time):''}" disabled>
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Refund_msg')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-refund_msg" class="form-control" name="row[refund_msg]" type="text" value="{$row.refund_msg}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('transfer_arr')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-transfer_arr" class="form-control" name="row[transfer_arr]" type="text" value="{$row.transfer_arr}">
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>
